Comparison Between Hyaluronic Acid and Platelet-Rich Plasma, Intra-articular Infiltration in the Treatment of Gonarthrosis.
Cerza F, Carni S, Carcangiu A, Di Vavo I, Schiavilla V, Pecora A, De Biasi G, & Ciuffreda M. Am J Sports Med. 2012 vol. 40(12): 2822-2827.
Osteoarthritis (also known as gonarthrosis) is characterized by structural and biochemical changes throughout the entire joint. Unfortunately, osteoarthritis can be challenging to treat and no treatments have been demonstrated to slow, halt, or reverse osteoarthritis progression. Recently, it has been hypothesized that hyaluronic acid (HA), a key component of synovial fluid, or platelet-rich plasma (PRP), which contains various growth factors involved in the inflammatory/healing process, may be good therapies for osteoarthritis. Therefore, Cerza and colleagues conducted a randomized trial to compare the clinical responses to HA and PRP treatment in 2 groups of patients affected by knee osteoarthritis (Kellgren-Lawrence grades 1 – 3; mild-moderate disease). The study included 120 patients that had only received physical therapy and pharmacological treatment, excluding those that had previous knee operations, infiltrative (intra-articular injections) treatment, or an autoimmune syndrome. Sixty patients received 4 weekly injections of a specific PRP, autologous conditioned plasma, which was chosen because of its high content of growth factors and low content of white blood cells. The other sixty patients received 4 weekly injections of HA. All patients were evaluated before the injection series was started and at 4, 12, and 24 weeks using the Western Ontario and McMaster (WOMAC) osteoarthritis index questionnaire (graded 0-96, higher score represents increased debilitation). Both groups were found to have similar pretreatment WOMAC scores: 76.9 for the PRP group and 75.4 for the HA group. At weeks 4, 12, and 24, the PRP group had better WOMAC scores of 49.6, 39.1, and 36.5, compared to the HA group with scores of 55.2, 57.0, and 65.1. The differences found between the groups were significant at each time point, as well as significantly better than the baseline results at each time point. The grade of osteoarthritis did not influence the results within the group treated with PRP, whereas within the HA group individuals with grade 3 osteoarthritis showed less improvement compared to individuals with grades 1 and 2 (milder disease) at weeks 12 and 24.
Many patients suffer from knee osteoarthritis, some at an earlier age secondary to injuries suffered as an athlete or the rising rate of obesity. With some providers having concerns about the long-term use of corticosteroid injections on younger patients, other options for treatment such as HA and PRP have been looked at more closely. This study had similar outcomes to an article reviewed in April 2012 looking at PRP vs HA in talarosteochondral lesions. Although both groups were found to have improvements compared to baseline in this study, the PRP group continued to show improvement at 24 weeks, while the HA group’s peak effect was at 4 weeks and worsened after that. It is important to note that these results differ slightly from another recent article by Filardo et al (2012) that suggested the two treatments overall had similar outcomes but there was some signs that among those with milder disease PRP was favorable to HA. Although more research is needed with larger numbers of patients and longer follow-up, these results are promising and can be added to the list of PRP studies with positive results. As far as how this effects treatment decisions, it would be helpful to have studies that also compares corticosteroid injections to both PRP and HA. Corticosteroid injections are still the first-line treatment when using intra-articular injections for knee osteoarthritis. Until PRP is covered by health insurances, HA injections will still likely be 2nd line for the general population. Do you have any experiences with the use of PRP for knee osteoarthritis? The authors discuss PRP having an anti-inflammatory effect in this setting when using a product with low white blood cells. What are your thoughts regarding PRP typically being understood as having a pro-inflammatory reaction when used for tendinopathy treatment?
Written by: Kris Fayock, MD
Reviewed by: Jeffrey B. Driban
Cerza F, Carnì S, Carcangiu A, Di Vavo I, Schiavilla V, Pecora A, De Biasi G, & Ciuffreda M (2012). Comparison Between Hyaluronic Acid and Platelet-Rich Plasma, Intra-articular Infiltration in the Treatment of Gonarthrosis. The American Journal of Sports Medicine, 40 (12), 2822-7 PMID: 23104611